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1 Tropical Medicine and International Health doi: /j x volume 12 no 2 pp february 2007 Editorial: A view from beneath: Community Health Insurance in Africa Pascal Ndiaye 1, Werner Soors 2 and Bart Criel 2 1 Initiative de Communication pour le Développement Social (ICODES)-Afrique, Dakar, Senegal 2 Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium Summary This paper presents an overview of the development of Community Health Insurance (CHI) in sub- Saharan Africa. In 2003, nearly 600 CHI initiatives were registered in a dozen countries of francophone West Africa alone. At regional level, coordination networks have been created in Africa with the aim to support and monitor the developments of this innovative model of health care financing. At national level, governments are preparing the necessary legal frameworks for CHI implementation. CHI is increasingly seen as a strategy to meet other development goals than only health. It constitutes an interesting model to finance health care, to pool financial resources in a fair way and to empower health care users. The CHI movement however still faces many challenges. The relevance of more professional inputs in the management of CHI and the need for careful subsidy of CHI are increasingly recognized. There is also need to optimize the relationship of CHI with the other actors in the health system and to scale-up CHI so as to gain in effectiveness and efficiency. The boom in the number of in Africa during the last years is an indicator of the increasing attractiveness of the model. In practice however, enrolment rates per scheme remain low or are only slowly increasing. Context-specific research is needed on the reasons that prevent people from enrolling in larger numbers. On that basis, relevant action to be taken locally can be identified. keywords community health insurance, access, financing, user empowerment, sub-saharan Africa Access to decent health care is a global problem that is strongly linked with worldwide changes in health care financing. It is a particularly great problem in sub-saharan Africa, the only region in the world with negative economic growth for decades now. The policy of free care at the point of use, the option taken in most African countries in the early independence days of the 1960s, became unsupportable and was gradually abandoned in the deepening economic and financial crisis of the 1970s and 1980s. From 1987 on, the donor-driven Bamako Initiative tried to remedy this, linking up community participation with community financing in health care. User fee policies contributed to increase the level of resources available in health care facilities and led to improvements in the quality of health care delivery in some settings (Levy-Bruhl et al. 1997). But user fees also constitute a strong barrier to health care for many African households trapped in poverty and excluded from formal social security systems. It is in this context that Community Health Insurance (CHI) emerged in the late 1980s and early 1990s (Brouillet et al. 1997; Dror & Jacquier 1999). CHI was largely inspired by the continental European experience with Social Health Insurance (Gruat 1990; Normand & Weber 1996; Criel & Van Dormael 1998). Initiated by private non-forprofit health care providers, for instance church-related organizations in Senegal and Ghana, or non-governmental organizations in the Democratic Republic of Congo, driven by the search of health providers for funds to operate their services, or by a combination of both, the movement was picked up by a growing number of communities and socioprofessional groups excluded from formal social security (Criel 1998; Atim 1999). The principles are simple: on a voluntary basis individuals or households join a non-forprofit structure to share the financial risk of individual health care expenditure; together they decide on the services covered and the contribution charged. Solidarity is by no means a new phenomenon in African culture. Neighbour support has been a long-lasting tradition and has a place in almost any life event of the African household. A wide variety of arrangements of informal risk sharing and coping mechanisms exist, such as rotating savings and credit associations, burial societies and friendsin-need-groups. However, the increasing burden of demographic growth, economic decline and structural adjustment policies, as well as urban migration paired with profound changes in the social fabric of communities ª 2007 Blackwell Publishing Ltd 157

2 outweighed the soothing potential of overstretched traditional solidarity mechanisms. Governments and donors recognized the potential of CHI as a strategy to increase access to health care under adverse conditions. The movement gained strength and in 1998 several African countries, international partners and local actors met in Abidjan, the capital of Ivory Coast. Together they created the coordination network Concertation entre les acteurs du développement des mutuelles de santé en Afrique, currently known and referred to as La Concertation. The aim of this network was to support and monitor the developments of CHI in sub-saharan Africa 1. It is now gradually extending its activities from francophone to anglophone Africa and from West to Central Africa. In East Africa a similar, but smaller, network also operates: the Community Health Financing Association for Eastern Africa (CHeFA-EA). It currently offers support to CHI in Kenya, Tanzania and Uganda. Increasingly, contacts are established between these two coordination networks. A takeoff at different speeds The boost of CHI in West Africa has led to a fast sixfold overall increase in the period (Concertation entre les acteurs de développement des mutuelles de santé en Afrique 2004). Table 1 provides an overview count of the nearly 600 CHI initiatives registered in francophone West Africa in the period (Atim 2000; Concertation entre les acteurs de développement des mutuelles de santé en Afrique 2000, 2004). The data for 2006 are based on recent estimates provided by key informants in each of the countries concerned. In 2006, the number of functional CHI in the 11 countries surveyed was 626, which is almost double the number of functional in Considering the total number of CHIs, forerunner Senegal also appears as a foregoer. Next are Guinea, Burkina Faso and Mali, followed by Benin, Cameroon and the Ivory Coast. The Niger, Chad, Togo and Mauritania modestly close the ranking. A closer look at country level discloses not only different speeds but also particular modalities of implementation. In Mali the CHI movement benefited since its early stage from the presence of the Technical Union of Community Health Insurance, the Union Technique de la Mutualité Malienne (UTM). The federation offers community groups their own CHI tailored to local needs and further serves as an interface between the movement and the government. Initially relying on organized formal 1 urban workers, the UTM now addresses successfully both the informal sector and the rural communities. In Senegal CHI went the other way, expanding gradually from rural villages to urban and periurban settings and from the informal to the formal sector. New initiatives keep emerging. Today formal workers are adopting the CHI concept as a welcome complement to poorly performing formal social security arrangements. The Senegalese State supports the CHI concept and provided a legal framework and a strategic plan for CHI development. Guinea presents another particularity: a research project (the PRIMA project: Projet de Recherche sur le Partage du Risque Maladie) set out the stakes back in 1996 (Le projet PRIMA en Guinée Conakry 2002). More recently the implementation of MURIGA (Mutuelles pour les Risques liés à la Grossesse et à l Accouchement, i.e. CHI for the management of pregnancy and birth related risks), differing from the classical CHI concept in its more narrow target group, provides a possible entry-point for yet additional risk-sharing among people. Burkina Faso initially concentrated on the extension of CHI led by health care providers themselves, but today community-run CHI are increasingly common; Benin focuses on the involvement of locally elected leaders. Cameroon, Niger and Mauritania got involved only recently, but can rely on strong social and religious networks. Ivory Coast, Niger, Chad, Togo and Mauritania still lag somewhat behind. However, intense activity from the planners side possibly indicates a forthcoming CHI boom in these countries. The case of Ghana in anglophone West Africa is particular because different types of CHI exist for more than 10 years. The initiative for these was taken at local level by hospital managers, district health management teams, unions, civil society organizations and villagers. More recently, the government took the initiative to promote health insurance in the form of district insurance and in 2004 new legislation was introduced that establishes a framework for the implementation of these district. This inventory commissioned by La Concertation did not include Central and Eastern Africa, but CHI is enjoying an increasing interest there. A particular feature of the situation of CHI in that part of the African continent is the fact that governments and health care providers tend to play a more prominent role in the launching and management of CHI (Waelkens & Criel 2004). In Uganda, a dozen of CHI exit and almost all of them were launched and are managed by hospital staff from faith-based health care facilities. In Tanzania, the government has played a major role in launching CHI at district level with support 158 ª 2007 Blackwell Publishing Ltd

3 Table 1 Community Health Insurance in West Africa Schemes in start-up phase Schemes in difficulty Total number of Total number of beneficiaries Estimated number of functional Benin Burkina Faso Cameroon Chad Guinea Ivory Coast Mali Mauritania Niger Senegal Togo Total from the World Bank. But private not-for-profit, mainly hospital-based, CHI also exist in Tanzania. Small but personalized experiences The majority of African CHI only count a few hundreds of members, 95% of the having <1000 members households are the usual unit of membership meaning that the number of individual beneficiaries from the is much higher (Table 1). Most of the members keep strongly linked to a well-defined but limited social basis, like a village, a church or a professional group. These features lead to high transaction costs and limit the efficient and sustainable coverage of expensive risks, such as hospital admissions or costly or prolonged drug expenditure. This is one of the reasons why many of the CHI only cover basic primary care and essential generic drugs. Many are managed or co-managed by the members themselves, but the limitations of management by non-professionals are increasingly recognized. Smallness has more than only disadvantages. Members generally know each other and sometimes play an active role in the management of the scheme. CHI is increasingly seen as a road to meet other development objectives beyond health. The increased social control and transparency observed in the presence of a well-implemented CHI may boost sustainable development and democratization at community level. An expected outcome in health, next to better access to health care, is the possibility to empower users (and potential users) in their interaction with professional health care providers, and thus to weigh on the supply side. There is evidence, albeit still limited and unsystematic, that CHI can lead to a more balanced power relationship with the health care providers, and thus constitute a leverage to have service packages that are more in line with local needs and to increase quality of care (Criel & Waelkens 2003; Waelkens & Criel 2004). Furthermore, the inventory of La Concertation indicates that CHI handles activities additional to health insurance in more than 60% of the West African CHI, especially in Cameroon, Guinea and Burkina Faso. The most frequently associated activities include the provision of micro-credits and of health care services. This relation runs in both directions: 33% of micro-credit organizations report health insurance as an associated activity. Beyond community level, CHI may eventually contribute to poverty reduction (Waelkens et al. 2005). Increasing national and international interest At national level several African countries have developed legal frameworks for CHI implementation (Ghana and Senegal), even making membership mandatory (Rwanda and Tanzania). An increasing number of countries plan such legislation as well. At regional level the participation to the bi-annual meeting of the members of the Concertation (Le Forum de la Concertation) is an indication of the growing interest in CHI by a variety of stakeholders, as witnessed by the boom in attendances from 80 participants in 2000 till 372 in Equally remarkable is the widening scope of present actors, including major national and international stakeholders. Noteworthy for the maturation of the CHI movement is the evolution of the discussion themes at the bi-annual meeting of the members of the Concertation. Whereas in 2000 the central focus was still on the design of CHI, the ª 2007 Blackwell Publishing Ltd 159

4 attention progressively shifted in the years after to a discussion on managerial tools for an improved performance, and to the study of means to structure the relationships of CHI with the other actors in the system (especially the health care providers) and of strategies to smoothen the integration of CHI in local health systems. The CHI movement not only acquired important managerial skills, it increasingly displays a systemic vision on health care delivery (Ndiaye 2006). Challenges and promises But no balanced opinion on CHI in Africa can bypass the many limitations and challenges the movement still faces. One of the pressing issues is the need to optimize the relationship of CHI with the other actors in the health system, including health committees, service providers, the State and the donor community. CHI are still considered as rivals by health committees, as watchmen by reception staff in health facilities cut off from under-thecounter payments and as untrustworthy payers by service providers. It takes providers time to understand the objectives of CHI and to appreciate their impact on service provision. Where interests meet, a functioning integrated local health system can be achieved with providers enjoying more stable revenues. Another important challenge for the CHI movement is the need for scaling-up and professionalizing CHI management without losing the advantages of a personalized approach. One possible path to reach this goal is the creation of networks or federations of CHI. This strategy is already carefully considered or applied in several West African countries (Mali, Senegal, Guinea). Networking offers the potential to cover rare but very costly events like hospital admissions. It can also strengthen the financial robustness of CHI, develop managerial capacity and help create a platform for advocacy and lobbying at the national level. The Union des Mutuelles de Santé de Dakar (UMSD) in Senegal and the Union Technique de la Mutualité (UTM) in Mali are distinctive examples that succeeded in gaining collective strength and professionalism by entrusting managerial and promotional tasks to a shared central structure. It is important for donors to understand the specificity of CHI and the need for time for it to develop. The implementation of CHI is a complex technical, managerial and social operation. It took European Social Health Insurance systems many decades to develop. Donors can definitely contribute to a harmonious development of CHI by not handling unrealistic (short-term) objectives and time frames, by strengthening local capacity in terms of design and follow-up of CHI and by an intelligent use of subsidies in order to make CHI more affordable for the poorest in society. We argue for more attention from donors for the social and political dimensions of the African CHI movement, next to its potential to improve people s access to health care. More and broader knowledge for action is needed As we have argued in this paper, CHI constitutes an interesting model to finance health care in sub-saharan Africa. CHI enables to pool resources in a fair way and thus to share the burden of health care financing among many. It can create a stable resource of income for health care providers. Last but not least, it can constitute an innovative model of organizing and empowering users in their interaction with health care providers. The recent boom in the number of in Africa is an indicator of the increasing attractiveness of the model. In practice however, enrolment rates per scheme remain low or are only slowly increasing. Today we know some of the more important reasons: poor quality of care, limited ability to pay and lack of trust in the management. Next to these other factors should be considered: the designs and the extent to which the package of benefits fits people s demands and needs, the information people have on the, the distance from people s homestead to the health facilities where care is delivered, etc. Introducing health insurance in African societies, where households needs are multiple and pressing, and where insurance is altogether a new cultural concept, is a complex undertaking. We need more systematic, multi-country research on the causes that prevent people from enrolling in CHI en masse. Then actions to be taken can be identified tailored to each setting. Finally, two important lessons are now increasingly clear and should trickle down to the field. First, the need for more professional inputs in the support, management and follow-up of CHI. Secondly, the need for careful subsidies to cover the poorest households without however undermining and jeopardizing local solidarity dynamics. References Atim C (1999) Social movements and health insurance: a critical evaluation of voluntary, non-profit insurance with case studies from Ghana and Cameroon. Social Science and Medicine 48, Atim C (2000) Contribution des mutuelles de santé au financement, à la fourniture et à l accès aux soins de santé: synthèse des travaux de recherche menés dans neuf pays d Afrique de l Ouest et du Centre. Abt Associates Inc., Bethesda. 160 ª 2007 Blackwell Publishing Ltd

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